Provider Demographics
NPI:1407860075
Name:GLASS, STEPHEN G (EDM)
Entity Type:Individual
Prefix:MR
First Name:STEPHEN
Middle Name:G
Last Name:GLASS
Suffix:
Gender:M
Credentials:EDM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:176 OLD FORGE XING
Mailing Address - Street 2:
Mailing Address - City:DEVON
Mailing Address - State:PA
Mailing Address - Zip Code:19333-1121
Mailing Address - Country:US
Mailing Address - Phone:610-688-1138
Mailing Address - Fax:
Practice Address - Street 1:176 OLD FORGE XING
Practice Address - Street 2:
Practice Address - City:DEVON
Practice Address - State:PA
Practice Address - Zip Code:19333-1121
Practice Address - Country:US
Practice Address - Phone:610-688-1138
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS003422L103TC0700X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAJ90409OtherINTERCOUNY HEALTH PLAN
PAJ90409OtherINTERCOUNY HEALTH PLAN